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DEAR DR.PAUL: My son has asthma and seems to be always sick. I went to see a specialist who prescribed an inhaled steroid puffer. I am concerned about giving steroids to children. What do you think?

PEDIATRICIAN DR.PAUL ANSWERS: You have touched upon an issue very close to my heart. When I first started working in a Pediatric hospital, one of my first duties was to set up an asthma program. I believed then and still today, that we can control asthma with a combination of effective medications and proper education. Taking control of a child's asthma means understanding its cause and the role or purpose of the medications prescribed.

Before addressing your question, let me review how our understanding of asthma has evolved over the past 30 years. In the 1970's we understood asthma to be a condition in which the bronchi(airway tubes) close down abnormally as a reaction to a trigger(Brochospasm). Consequently, the treatment focused on medications known as broncholdilators, that opened up the airway. Alarmingly, despite increasing bronchodilator use, the rate of asthma(and its complications) increased. Indeed among children, asthma was one of the leading reasons for emergency room visits and hospitalization. Reflecting this, I coined the term the "viscious asthma cycle" describing a child who would go the emergency room, get admitted to hospital, get better, return home and a few weeks later go through the cycle again. What has helped to break this cycle? Our realization that inflammation is a major cause of symptoms in asthmatic children who are not well controlled and that the best treatment for reducing this inflammation are steroids. I do not mean the types of steroids that athletes use, but rather corticosteroids that are available in oral, intra-venous and inhaled forms. We all are aware of the potential effects of taking cortisone daily by mouth, which include stunting of growth, bone problems and hormonal imbalances. Thankfully, this is where inhaled steroids, administered via puffers or other similar devices, fit in. They are designed to specifically target the bronchi so very little gets into the blood, reducing the chance of any potential effects on the rest of the body.

Inhaled steroids have been shown in a number of studies, including a recent one, to be safe and specifically not to adversely affect growth in children. Older studies that suggested inhaled steroids slow down growth, did not take into account that uncontrolled asthma itself can prevent normal growth; I have treated children who were not growing well as a result of their severe asthma with inhaled steroids. As a result of better asthma control they resumed normal growth. Of course with any medication there are potential side effects, but asthma is not without its own dangers. Unfortunately and tragically, asthma can be fatal.

Aside from education and environmental control, inhaled steroids are the most important components in controlling asthma over the long term and preventing its potentially very serious complications. Reassuringly, the recent study confirming that they do not affect growth in children further solidifies their important role. Not all asthmatic children need inhaled steroids, but for those who do, I think this information is very reassuring.

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